Traumatic Injuries

Your character's just taken a nasty wound. Now just how dangerous is it?

Shocks
A great many injuries will induce hypovolemic shock, a complex set of reactions evolved to compensate for loss of blood pressure. In shock, blood is diverted from skin and muscles to vital organs, and platelet aggregation is increased. Note that septic shock has essentially the same symptoms. 

Mild to Moderate Shock:  
10%-25% of blood lost. The patient will be pale, have rapid, shallow breathing and have a high heart rate, will sweat and will feel quite weak. He will be thirsty, his extremities will be cool and his senses will start to cloud. Even the most stout of heroes will start to feel a rising panic from purely physiologic hormonal reactions. 

Severe Shock:  
(30%-50% of blood lost). Platelet aggregation in the lungs will lead to respiratory failure. Failure of cellular processes will lead to sequential systems failure, frequently starting with the heart and kidney. Basically you stop breathing, your heart stops, everything else fails and you die. This can take anywhere from hours to days after the initial injury. 

Extremities
Arms and legs. Minor damage will make the extremity painful or difficult to use; major damage will make it impossible to use. Major blood vessels may be damaged, leading to heavy haemorrhage. Joints can be dislocated, bones broken, muscles and tendons cut. Note that damage to the shoulder blades or clavicles will make the arm nigh on unusable. 

Sepsis
Fever, shock, decreasing mental status can easily lead to death if untreated. A common problem especially with poor medical care in the days and weeks after injury. 

Unconsciousness
What makes you fall unconscious is either direct injury to the brain, or inability to feed it enough blood or oxygen. If you lose all blood supply to the brain you fall unconscious in seconds. Massive haemorrhage can lead blood pressure to drop fast enough that unconsciousness follows in seconds to minutes. If you lose oxygen supply, you fall unconscious in 4-30 minutes, depending upon how restricted your air supply is. Poisoning  as from sepsis can also cause unconsciousness. 

Chest (Thoracic) Injuries 
Trauma that is inflicted on the chest can result in damage to the chest wall, lungs, trachea, major bronchi, oesophagus, thoracic duct, heart, diaphragm, mediastinal vessels, and spinal cord. Any combination of these injuries may occur. 

Abdominal and Pelvic Injuries
The principal immediate danger resulting from abdominal and pelvic trauma is profound hemodynamic instability resulting from injury to the spleen, pancreas, liver, kidney, or tributaries of the aorta. Most abdominal injuries result in poorly localised and non specific pain, nausea and reflex vomiting. In general blunt injuries to the abdomen are more dangerous than penetrating injuries. 

Aorta and Arteries
With modern medical care, 85% of patients with multiple aortic ruptures will die at the scene, 20% of the survivours die within six hours, and 72% of the remainder will die within a week. Massive hemothorax and loss of blood pressure are the most common symptoms for penetrating injury. However for blunt injury initial manifestations are pain behind the sternum or between the shoulder blades, difficulty in swallowing, hoarseness, and difficulty breathing, leading to a left hemothorax and increasing levels of shock. 

Blood Vessels
Injury to major blood vessels in the abdomen may cut off the blood supply for the legs, making it impossible to stand in very short order. Depending upon where they're damaged, they make drain into the upper legs, causing extreme swelling. 

Collar Bone or Shoulder Blade Fractures:
Until it's splinted; pain in moving at all, inability to use the arm effectively, pain in attempting to use the arm. Can't really be fatal.

Diaphragm
A penetrating chest wound at or below the level of the nipple is likely to enter the chest, pierce the diaphragm, and enter the abdominal cavity. Since the diaphragm is the muscle you use to breathe, injury to the diaphragm results in respiratory distress, often associated with hemothorax, pneumothorax and shock. 

Flail Chest:  
The ribs or the sternum are broken in such a way that breathing moves air from one part of the lungs to another, rather than in and out. This will usually result in unconsciousness from low oxygen in fifteen minutes to an hour, but not death. 

Heart
Damage to the heart may result in massive blood loss, heart failure, and death in short order. However, less severe injuries can result in bleeding into the pericardial sack. When this fills up with blood it will put pressure on the heart, making it more difficult to beat, lowering blood pressure. The patient will initially feel very tired, leading to increasing stages of shock shortly. 

Intestines
Abdominal pain and peritonitis. Peritonitis is an inflammation of the tissue that lines the abdominal cavity. Starting a day or so after the injury, it will lead to severe abdominal pain and distention, fever, vomiting, thirst, and if left untreated death in a week or two. It is easily treatable. Injury to the duodenum leads to more severe symptoms (severe abdominal tenderness in the upper right quadrant, sever vomiting), rise of fever within hours, and may have hemodynamic instability with time. Note that evisceration isn't automatically fatal. In the absence of major haemorrhage, especially if the intestines aren't otherwise damaged, but that with poor medical care sepsis will probably be a killer. 

Pelvis Fracture
Besides making it impossible to stand, it is likely to cut one of the major blood vessels leading into the legs. Pelvis fractures are commonly associated with massive haemorrhage. 

Pulmonary Parenchyma
Lacerations of the lungs may cause pneumothorax as well as bleeding into the lungs. Contusions (blunt damage) will cause swelling of interstitial tissues and bleeding into the small airways. In either case, the patient will have difficulty breathing and will probably be coughing blood or exhaling blood. If this is severe enough low oxygen may lead to unconsciousness and death. 

Rib Fractures
The main symptom of rib fractures is that it hurts to breathe which will make exertion difficult. The amount it hurts depends on how many ribs are broken (a broken sternum is especially painful). Beyond this unless the patient has flail chest, hemothorax, the ribs have damaged the lung, or the ribs are displaced to such an extent that their motion damages surrounding tissue, the ribs will probably be held in place by the surrounding muscle and are largely ignorable. 

Spleen or Liver
Abdominal pain in the upper left (spleen) or upper right (liver) quadrant, severe haemorrhage rapidly leading to increasing shock and death. The mortality rate without intervention is near 100% for splenic injuries and almost as high for blunt injuries of the liver. 
Sepsis (inflammation or infection) is a major postoperative complication for liver injuries. Splenic rupture can also occur up to two weeks after the initial injury, as an initial clot dissolves, or the splenic capsule ruptures under pressure of an initially small haemorrhage. 

Stomach Muscles
Damage to the stomach muscles will make it difficult or impossible to stand. 

Sucking Wounds
A person inhales by moving a muscle called the diaphragm, creating a vacuum in the chest, which pulls air in through the mouth down into the lungs. However if there is a hole in the chest wall, air can enter through that hole instead, preventing air from entering the lungs. The patient will feel short of breath, air will visibly be being sucked in through the hole in the chest wall. The resulting low oxygen will usually result in unconsciousness in fifteen minutes to an hour, but is unlikely to be fatal on a short time scale. 

Tension Pneumothorax
Sometimes, a hole in the chest wall acts as a one way valve, letting air in, but not out again. Sometimes the lung is punctured without the chest wall being punctured ( from a broken rib, for instance ). Alternatively if a wound that punctured both the chest wall and the lung is treated with a tight compress, air will still escape from the lung but not from the chest cavity. In these cases the increasing air pressure in the chest cavity will cause hyperinflation of the chest, preventing the patient from breathing. The patient will have rapid, shallow breathing. He will fall unconscious from low oxygen in fifteen minutes or so, and will probably suffocate if left untreated. 
Tension Hemothorax is a similar problem but in this case it results from blood filling up the chest cavity. The patient will probably be suffering from shock, as well as suffocation. This will usually result from multiple rib fractures damaging internal tissues. Frequently seen together with tension pneumothorax. 

Urinary Tract
Abdominal pain, back or flank pain, inability to void or blood in the urine. Some kidney injuries will result in massive haemorrhage, but others will not. In the long term, damage to the kidney may lead to renal failure (this can also be caused by shock and sepsis.) The course of renal failure can last weeks to months. This is fatal more than 50% of the time. 

Head Injuries 
Face
All sort of bones can be broken in the face; the face plate, sinuses, cheekbones, the orbits of the eye, and of course, the nose. There are a wide variety of possible symptoms, but severe facial injury usually results in progressive swelling, resulting in difficulty breathing, inhalation of blood, frequently eventually (1 hour) completely closing off the airways, resulting in suffocation. There may also be numbness or paralysis in some part of the face. Facial injuries can also lead to extreme haemorrhage and shock.

Jaw
A broken jaw is associated with numbness, bleeding from tooth sockets, fractured or missing teeth, inability to close the jaw properly (teeth don't come together right), pain on moving the jaw, and sometimes with bleeding from the ear. Fractures of the jaw also allow the tongue and other soft tissues to intrude into the airway, leading to suffocation. 

Scalp
Scalp wounds bleed copiously, making it a major source of haemorrhage and shock. They may also be incidental to damage to the skull. 

Skull
Skull fractures in different places have rather different effects, but symptoms include one or more of the following; a mixture of blood and cerebrospinal fluid leaking from the ears, nose, or throat, blood in the whites of the eyes, loss of the sense of smell, loss of vision in one eye, a dilated, fixed pupil, a worsening in the patients level of consciousness. These last symptoms are indicative of pressure on the brain, caused either by swelling of the brain or bleeding into the skull. Swelling of the brain can cause serious damage or possibly death on its own, but has the advantage that its self-limiting (and in a modern setting, usually controllable with drugs). On the other hand, haemorrhage will almost always lead to continued degradation and death if left untreated. 
The patient may have a headache localised at the injury. He may be lucid for a period after the injury, but this will rarely be a period of normalcy. He will usually feel drowsy, and may thereafter slip into a coma. The patient will lose one set of reflexes after another. He may gradually lose the use of one of his arms or legs, or become completely paralysed on one side of the body. This will happen gradually as pressure increases starting with a slurring of speech and clumsiness. His breathing may become uneven, and some part or all of his body may begin shaking uncontrollably (seizure activity.) 
The time course for these degradations can be hours or days and the condition can worsen dramatically in minutes. 

Even the most minor head injury will result in the character being stunned for D4 rounds (all abilities halved).

Neck Injuries 
There are a lot of important things passing through the neck, including the spinal cord, larynx and trachea, phrenic nerve, brachial plexus, carotid artery, jugular vein, cranial nerves, oesophagus and pharynx, thyroid gland, and stellate ganglion. Of course, many of these may be damaged simultaneously. Possible symptoms for damage to each of these are listed below. Not all will necessarily be present. 

Brachial Plexus: numbness and/or partial paralysis in an arm. 

Carotid artery: decreased level of consciousness, heavy bleeding (which may compress the trachea causing difficulty breathing), and hypovolemic shock. 

Cranial nerves: inability to shrug a shoulder or rotate chin to opposite shoulder, paralysis of the tongue, hoarseness, and difficulty in swallowing. 

Jugular vein: heavy bleeding, hypovolemic shock. 

Larynx and trachea: spitting blood, a sucking neck wound, hoarseness, difficulty breathing, high pitched, noisy respiration. 

Oesophagus and pharynx (connects to your stomach): difficulty swallowing, bloody saliva, sucking neck wound. 

Spinal cord: partial or total paralysis. 

Stellate ganglion: dilated pupil. 

Thyroid gland, phrenic nerve: no special short term effects. Also, damage to the muscles in the neck will mean that the patient is unable to hold his head upright. 

 

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